|Year : 2021 | Volume
| Issue : 1 | Page : 77
Association between dietary fat intake and odds of Gastro-esophageal Reflux Disorder. (GERD) in Iranian adults
Soraiya Ebrahimpour-Koujan1, Ammar Hassanzadeh Keshteli2, Ahmad Esmaillzadeh3, Peyman Adibi4
1 Students' Scientific Research Center; Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
2 Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Students' Scientific Research Center; Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular -Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran; Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||01-Oct-2018|
|Date of Acceptance||18-Apr-2020|
|Date of Web Publication||05-Jul-2021|
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, PO Box 14155-6117
Source of Support: None, Conflict of Interest: None
Background: Most information on the association of dietary fat intake and gastro-esophageal reflux disorder (GERD) came from developed countries, where lifestyle and other dietary components might be different from those in developing countries. This cross-sectional study was, therefore, conducted to investigate the association between dietary fat intake and odds of having GERD in a large group of Iranian population. Study Design: This cross-sectional study was done among 3362 adult population in Isfahan, Iran. Dietary intakes were collected by the use of a validated semi-quantitative food frequency questionnaire. Methods: Assessment of GERD was done using a validated self-administered questionnaire examining the frequency of heartburn in the last 3 months. Individuals with the presence of heartburn symptoms sometimes, often or always during the last 3 months were defined as having GERD. Results: Participants in the top category of dietary fat intake had higher daily intakes of energy, macronutrients and micronutrients. Dietary intakes of all food groups were also significantly higher among those in the top quintile as compared with those in the bottom category of dietary fat intake (P < 0.001 for all). There were no significant associations between dietary fat intake and incidence of GERD in general population. Crude and multivariable-adjusted models revealed no significant associations between dietary fat intake and having GERD in either gender. Conclusions: We found no significant association between dietary fat intake and odds of having GERD in this population. Further studies, in particular of prospective designs, are warranted to clarify this association.
Keywords: Cross-sectional studies, dietary fats, gastroesophageal reflux
|How to cite this article:|
Ebrahimpour-Koujan S, Keshteli AH, Esmaillzadeh A, Adibi P. Association between dietary fat intake and odds of Gastro-esophageal Reflux Disorder. (GERD) in Iranian adults. Int J Prev Med 2021;12:77
|How to cite this URL:|
Ebrahimpour-Koujan S, Keshteli AH, Esmaillzadeh A, Adibi P. Association between dietary fat intake and odds of Gastro-esophageal Reflux Disorder. (GERD) in Iranian adults. Int J Prev Med [serial online] 2021 [cited 2021 Dec 5];12:77. Available from: https://www.ijpvmjournal.net/text.asp?2021/12/1/77/320726
| Introduction|| |
Gastro-esophageal reflux disease (GERD) is one of the most common chronic upper gastro-intestinal tract diseases that exhibits large range of typical and atypical symptoms such as heartburn (a burning feeling behind the breast bone), regurgitation of acid of the gastro-duodenal into the esophagus, non-cardiac chest pain, chronic cough and hoarseness.,, It affects up to 1520% of adult population. The prevalence in Iranian adult population has been reported to be 21.2%.,, Individuals with GERD are at greater risk of dysphagia, esophagus ulcer, upper gastro-intestinal (GI) tract bleeding, stricture formation, Barrett's esophagus and metaplasia of the distal esophageal mucosa., Despite the considerable knowledge on GERD pathogenesis, its risk factors remain poorly understood. It seems that dietary intakes might also get involved in the prevalence and incidence of GERD symptoms. Patients with GERD are usually advised to avoid fatty foods because GERD episodes were increased after eating fatty foods. However, data in this regard are conflicting. Several experimental and clinical studies revealed that consumption of high fat foods decreased the lower esophagus sphincter (LES) pressure and increased the esophageal acid exposure., Findings from observational studies have indicated that subjects with the highest fat intake had a greater risk of reflux esophagitis and functional dyspepsia compared with those with the lowest intake., Others have also reported a positive association between high dietary fat intake and increased risk of GERD symptoms., However, data from National Health and Nutrition Examination Survey demonstrated that increased fat intake was not associated with greater odds of GERD.,, On the basis of national data, of the total of energy intake, 22% came from fats. Previous studies have mostly focused on frequency of fried foods intake and high fat meals, not total dietary fat intake.
Most information on the association of dietary fat intake and GERD came from developed countries, where lifestyle and other dietary components might be different from those in developing countries. In addition, almost all earlier investigations have been limited in sample size and have not considered the potential confounders. Given the inconsistencies in previous findings, it seems that additional data from large studies, controlling for a wide range of confounders, are required to shed light on this issue. This cross-sectional study was, therefore, conducted to investigate the association between dietary fat intake and odds of having GERD in a large group of Iranian population.
| Methods|| |
This cross-sectional study was undertaken within the “Study on the Epidemiology of Psychological, Alimentary Health and Nutrition” (SEPAHAN) project. The main aim of SEPAHAN was to investigate the association between lifestyle-related factors and functional gastrointestinal disorders. Information about study design, sampling method, data collection and participants' characteristics are described in detail elsewhere. In short, participants were recruited from the general population of Isfahan province, who were working in health centers affiliated with Isfahan University of Medical Sciences (IUMS). Data collection process of SEPAHAN project was conducted in two separate phases during April 2010 to May 2010. In the first phase, 10,087 self-administered questionnaires, containing information on demographics and dietary data, were distributed and 8,691 subjects responded (response rate: 86.16%) to the questions. In the second phase, information on gastrointestinal function was collected through sending the relevant questionnaires to 9,652 participants enrolled in the first phase and 6,239 questionnaires were completed and returned (response rate: 64.6%). No significant difference was seen in the demographic data of those returned the questionnaires and those that did not. In the current study, we excluded individuals with under- and over-reporting of energy intake (800–4200 kcal/day). We also excluded individuals who had missing data on dependent and independent variables, as well as on confounding factors. After these exclusions, data from 3362 participants remained for the current study. We obtained written informed consent from all subjects. The study was approved by the Regional Bioethics Committee of IUMS (nos. #189069, #189082, and #189086).
Assessment of dietary fat intake
Dietary data on fat intake were obtained using a validated Willett-format dish-based semi-quantitative food frequency questionnaire (DS-FFQ) including 106 items. This questionnaire was originally designed and validated specifically for Iranian adults. Detailed information about the development of the questionnaire, its foods list and frequency response categories as well as its validity was published previously., The questionnaire consisted of five main categories of foods and dishes: (1) mixed dishes (cooked or canned, 29 items); (2) grains (different types of bread, cakes, biscuits and potato, 10 items); (3) dairy products (dairies, butter, and cream, 9 items); (4) fruits and vegetables (22 items); and (5) miscellaneous food items and beverages (including sweets, fast foods, nuts, desserts, and beverages, 36 items).
Daily intake of fat for each participant was calculated using the US Department of Agriculture's (USDA) national nutrient databank. In the current analysis were used total saturated fatty acids (SFAs), total monounsaturated fatty acids (MUFAs), total polyunsaturated fatty acids (PUFAs), total trans fatty acids (TFAs) and cholesterol.
Assessment of gastro-esophageal reflux disorder (GERD)
In the current study, a validated self-administered questionnaire (validated ROME III questionnaire), assessing the frequency of heartburn in the last 3 months, was used. The questionnaire included the rating scale of never or rarely, sometimes, often, always. In addition, the severity of heartburn was asked as follow: mild, moderate, severe, and very severe. GERD was defined as the presence of heartburn symptoms sometimes, often or always during the last 3 months prior to meeting in the study.
Assessment of other variables
Demographic and anthropometric information age, gender, weight, and height were achieved self-administered questionnaires. Physical activity status was assessed by General Practice Physical Activity Questionnaire (GPPAQ). The levels of physical activity were categorized as doing exercise at never, <1 h/wk, 13 h/wk or >3 h/wk. Consequent self reported data collection; we categorized participants as non-smokers, ex-smokers or current smokers. The meal regularity was asked as never, sometimes, often or always. The eating rate was specified following question was asked: “how long does it take you to eat lunch or dinner?” and their answers including one of these subjects: I never eat lunch, <10 min, 1020 min, or >20 min. If the duration of the having lunch time was less than 10 minutes, it defined as rapid food eaters. We evaluated the frequency of breakfast consumption by following questions: “never or one day/wk, 24 days/wk, 56 days/wk or every day”. Breakfast skipping was characterized as eating breakfast never or one day per week. Meal-to-sleep interval was questioned as: “how long does it take you to go to sleep (or to lie down) after lunch (never sleep or lie down, <30 min, 0.5 <2 h, 24 h, >4 h)”, and after dinner (<30 min, 0.5 <2 h, 24 h, >4 h). Tea drinking pattern was assessed by using the pre-tested questionnaire. The frequency of tea consumption were include “never or less than 1 cup/month, 13 cups/month, 13 cups/wk, 46 cups/wk, 1 cup/day, 24 cups/day, 57 cups/day, 811 cups/day or at least 12 cups/day”. Similarly the status of coffee drinking and chocolate consumption were also evaluated through a self-administered questionnaire. Coffee drinking and chocolate consumption patterns were classified as never or less than 1 cup/month, 13 cups/month, 1 cups/wk, 24 cups/wk, 56 cups/wk, 1 cup/day, 23 cups/day, 45 cups/day, at least 6 cups/day), soft drink (never or less than 1 cup/month, 13 cups/month, 1 cups/wk, 24 cups/wk, 56 cups/wk, 1 cup/day, 23 cups/day, 45 cups/day; and never or less than once/month, 1–3 times/month, 1 times/wk, 2–4 times/wk, 56 times/wk, 12 times/day, 35 times/day, 69 times/day, at least 10 times/day; respectively.
Analyses were done separately by gender. First, participants were categorized based on quintiles of dietary fat intake. One-way analysis of variance was used to examine significant differences in continuous variables across quintiles of dietary fat intake. The distribution of participants in terms of categorical variables across quintiles was assessed by means of Chi-square test. Age and energy-adjusted intakes of foods and nutrients across quintiles of dietary fat intake were examined using analysis of covariance. To find the association between dietary fat intake and GERD, we used logistic regression in different models. First, Crude model was done without any adjustments. In adjusted model I, we controlled for age (continuous) and total calorie intake (continuous). Then we further controlled for physical activity (categorical), smoking (yes/no), diabetes (yes/no), supplement use (yes/no) and aspirin (yes/no). Additional adjustment was done for meal regularity (categorical), eating rate (categorical), chewing quality (categorical), intra-meal fluid intake (categorical), and after-meal lying down (categorical). In an additional model, we considered consumption of coffee, tea and, chocolate. Then in the final model, we took into account body mass index (BMI) to find if the associations were obesity independent. In all analyses, the first quintile of dietary fat intake was considered as a reference. To assess the overall trend of odds ratios across increasing quintiles of dietary fat intake, we treated the quintile categories as an ordinal variable in the analyses. All analyses were performed using SPSS software (version 19.0; SPSS Inc, Chicago IL). P values were considered significant at <0.05.
| Results|| |
General characteristics of study participants across categories of dietary fat intake are shown in [Table 1]. Females in highest quintile of dietary fat intake had higher BMI, were more likely to be younger, university graduated and greater percent of them had intra-meal fluid intake than those in the lowest quintile. Men in the top quintile of dietary fat intake had greater BMI. There was no significant difference in the distribution of men and women across quintile of dietary fat intake in terms of marital status, house owner, suffering from chronic conditions, doing exercise, supplement use, chewing quality, smoking status and aspirin use.
|Table 1: General characteristics and diet-related practices participants across quintiles of dietary fat intake|
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Dietary intakes of participants across categories of dietary fat intake are provided in [Table 2]. Participants, both males and females, in the top category of dietary fat intake had higher daily intakes of energy, macronutrients, saturated fats, monounsaturated fats, polyunsaturated fats, cholesterol and fiber, and micronutrients. Dietary intakes of all food groups including fruits, vegetables, white meat, red meat, low and high-fat dairy products, refined grains, whole grains and tea or coffee were also significantly higher among those in the top quintile as compared with those in the bottom category of dietary fat intake (P < 0.001 for all).
|Table 2: Dietary intakes of study participants across quintiles of dietary fat intake|
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Crude and multivariable-adjusted odds ratios and 95% class intervals (CIs) for having GERD across categories of dietary fat intake are indicated in [Table 3]. No significant associations were seen between dietary fat intake and incidence of GERD in either gender either before or after controlling for several potential confounders, including diet-related practices.
| Discussion|| |
The present cross-sectional study examined the association between dietary fat intake and risk of GERD in Iranian adult population. After controling for a wide range of potential confounders including diet-related practices, we found no significant association between dietary fat intake and prevalence of GERD either in men or women. This study is the first from the Middle Eastern population that assessed dietary fat intake in relation to GERD. To our knowledge, this study is among the first investigations in which diet-related habits have been taken into account when assessing dietary intakes in relation to upper gastrointestinal disorders.
GERD is one of most frequent gastrointestinal problems in both developed and developing countries. We found no significant association between dietary fat intake and prevalence of GERD in men or women. In line with ours, some other investigators found no relationship between dietary fat intake and risk of GERD.,, Fox et al. indicated no significant difference in reflux symptoms in patients with typical reflux disorder comparing those who consumed high-fat and low-fat diets. Furthermore, it has been demonstrated that consumption of a high fat meal did not increase the rate of reflux episodes in patients with esophageal reflux compared to control subjects. In contrast, some evidence from experimental and clinical studies suggested that reduced dietary fat intake might lower the risk of GERD.,,, For instance, El-Serag et al. reported that high dietary fat intake was associated with increased risk of GERD and erosive esophagitis; however, when they adjusted for BMI, the significant association disappeared. In addition, high saturated fat and cholesterol intake was linked to GERD only in participants with a BMI >25 kg/m2, not among those with a normal BMI. Also in a case-control study, higher risk of reflux esophagitis were seen among patients in the highest quartile of total dietary fat intake compared to those in the lowest quartile. These controversial findings might be attributed to differences in the study design, and subjects' characteristics. In addition, earlier studies have not controlled for a wide range of confounders including dietary habits, BMI, tea and coffee intake and smoking. These variables were taken into account in the current analysis.
Several points need to be considered in the interpretation of our findings. In this analysis, we did not consider the patient's status with regard to history of hiatal hernia. Diagnosis of GERD by subjective questionnaire was a limitation which might affect our findings. However, previous studies were used this scale. The most important limitation of this study was its cross-sectional design which would not help us to confer causality. Dietary assessment of fat intake in the current study was done by the use of FFQ, which would in turn lead to misclassification of participants in terms of dietary fat intake. However, this sort of bias is unlikely to affect the findings. Moreover, despite adjusting for a wide range of confounders including diet-related practices in the current study, there might be other factors including types of dietary fat among Iranian population, depression, stress and anxiety that might further confound the association. Therefore, residual confounding cannot be excluded. Large study population and controlling for major confounders including BMI are among several strengths of this study.
In conclusion, we did not find evidence indicating the association between dietary fat intakes and risk of GERD in this cross-sectional study. Further studies, in particular of prospective designs, are required to clarify this association.
Author wish to thank all staff of Isfahan University of Medical Sciences who kindly participated in present study and staff of Public Relations Unit, and other authorities of IUMS for their excellent cooperation. The project was supported by the Iran National Science Foundation (INSF).
Financial support and sponsorship
The Vice Chancellery for Research and Technology, Isfahan University of Medical Sciences financially supported SEPAHAN by a grant. Also, a Senior Research Fellowship from the National Health and Medical Research Council of Australia supported the C FeinleBisset (Grant no. 627002, 20102014).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Herregods TV, Bredenoord AJ, Smout AJ. Pathophysiology of gastroesophageal reflux disease: New understanding in a new era. Neurogastroenterol Motil 2015;27:1202-13.
El-Serag HB, Satia JA, Rabeneck L. Dietary intake and the risk of gastro-oesophageal reflux disease: A cross sectional study in volunteers. Gut 2005;54:11-7.
He D, Huang X, Wang ZP, Chen D, Chen J, Duan CY. Dietary fat intake and risk of esophageal carcinoma: A meta-analysis of observational studies. Oncotarget 2017;17;8:99049-56.
Delavari A, Moradi G, Birjandi F, Elahi E, Saberifiroozi M. The prevalence of gastroesophageal reflux disease (GERD) in the Islamic Republic of Iran: A systematic review. Middle East J Dig Dis 2012;4:5-15.
Ruhl CE, Everhart JE. Overweight, but not high dietary fat intake, increases risk of gastroesophageal reflux disease hospitalization: The NHANES I Epidemiologic Followup Study. First National Health and Nutrition Examination Survey. Ann Epidemiol 1999;9:424-35.
Fox M, Barr C, Nolan S, Lomer M, Anggiansah A, Wong T. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol 2007;5:439-44.
Festi D, Scaioli E, Baldi F, Vestito A, Pasqui F, Di Biase AR, et al
. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World J Gastroenterol 2009;15:1690-701.
Feinle-Bisset C, Azpiroz F. Dietary lipids and functional gastrointestinal disorders. Am J Gastroenterol 2013;108:737-47.
O'Doherty MG, Cantwell MM, Murray LJ, Anderson LA, Abnet CC; FINBAR Study Group. Dietary fat and meat intakes and risk of reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma. Int J Cancer 2011;129:1493-502.
Khodarahmi M, Azadbakht L. Dietary fat intake and functional dyspepsia. Adv Biomed Res. 2016;5:76.
Matsuki N, Fujita T, Watanabe N, Sugahara A, Watanabe A, Ishida T, et al
. Lifestyle factors associated with gastroesophageal reflux disease in the Japanese population. J Gastroenterol 2013;48:340-9.
Penagini R, Mangano M, and Bianchi P. Effect of increasing the fat content but not the energy load of a meal on gastro-oesophageal reflux and lower oesophageal sphincter motor function. Gut 1998;42:330-3.
Saberi-Firoozi M, Khademolhosseini F, Yousefi M, Mehrabani D, Zare N, Heydari ST. Risk factors of gastroesophageal reflux disease in Shiraz, southern Iran. World J Gastroenterol 2007;13:5486-91.
Esmaillzadeh A, Keshteli AH, Feizi A, Zaribaf F, Feinle-Bisset C, Adibi P. Patterns of diet-related practices and prevalence of gastro-esophageal reflux disease. Neurogastroenterol Motil 2013;25:831-e638.
Adibi P, Keshteli AH, Esmaillzadeh A, Afshar H, Roohafza H, Bagherian-Sararoudi R, et al
. The study on the epidemiology of psychological, alimentary health and nutrition (SEPAHAN): Overview of methodology. J Res Med Sci 2012;2:s291-7.
Keshteli A, Esmaillzadeh A, Rajaie S, Askari G, Feinle-Bisset C, Adibi P. A dish-based semi-quantitative food frequency questionnaire for assessment of dietary intakes in epidemiologic studies in Iran: Design and development. Int J Prev Med 2014;5:29-36.
Holden JM. Food sampling strategies for energy intake estimates. Am J Clin Nutr. 1995;62(5 Suppl):1151S-7S.
Chen KH, Mukaisho K, Sugihara H, Araki Y, Yamamoto G, Hattori T. High animal-fat intake changes the bile-acid composition of bile juice and enhances the development of Barrett's esophagus and esophageal adenocarcinoma in a rat duodenal-contents reflux model. Cancer Sci 2007;98:1683-8.
[Table 1], [Table 2], [Table 3]